INTRODUCTION: Pancreatic pleural effusion is a rare condition caused by direct leakage of pancreatic fluid into the thoracic cavity, resulting in massive pleural effusion. We report a case of massive pleural effusion due to intrathoracic perforation of a pancreatic pseudocyst successfully treated by thoracoscopic surgery. CASE PRESENTATION: A 36-year-old man with a history of chronic alcoholic pancreatitis presented with progressive dyspnea and was transported to Bokutoh Hospital. Chest radiography revealed a massive left pleural effusion with mediastinal shift to the right. Emergency thoracic drainage was performed, resulting in symptomatic improvement. Biochemical analysis of the pleural fluid showed markedly elevated amylase levels. Endoscopic retrograde cholangiopancreatography demonstrated contrast leakage from a pancreatic pseudocyst into the left thoracic cavity, leading to a diagnosis of intrathoracic perforation of a pancreatic pseudocyst. Endoscopic nasopancreatic drainage was performed, and subsequent imaging confirmed closure of the fistula. However, residual pleural effusion and impaired lung expansion persisted. Thoracoscopic decortication and drainage were therefore performed on day 17 of hospitalization. Intraoperatively, a large amount of black pleural fluid and thickened inflammatory pleura resembling empyema were observed. The postoperative course was uneventful, and the patient was discharged home on POD 37 without recurrence. CONCLUSIONS: When pleural effusion is observed in patients with chronic pancreatitis, pancreatic pleural effusion should be considered. Thoracoscopic surgery may be an effective treatment option, particularly in cases with persistent pleural inflammation after successful endoscopic management.

Robot-assisted thoracic surgery (RATS) has evolved toward reduced-port approaches to further minimize surgical invasiveness. However, current uniportal RATS techniques are associated with technical challenges, including limited working space and instrument interference, particularly in patients with smaller physiques. To overcome these limitations, we developed a non-assistant help operation in dual-portal RATS (neoDRATS), which fully utilizes all four arms of the da Vinci Xi system without canceling any arm. This technique enables console-surgeon-driven lung retraction and robotic stapling through a dual-portal configuration consisting of a 4-cm main incision and a single auxiliary port. In this article, we describe the step-by-step surgical technique of neoDRATS, including patient positioning, port placement, robotic arm configuration, use of the third arm, and robotic stapling strategies. Representative operative videos of right upper and left lower lobectomy are provided to illustrate key technical aspects and demonstrate the feasibility of this approach in clinical practice. neoDRATS offers a practical reduced-port RATS approach that balances minimal access with operative safety and maneuverability, while preserving familiar surgical views and workflows from conventional video-assisted thoracic surgery (VATS) and thoracotomy. This technique may facilitate the safe and reproducible adoption of reduced-port robotic thoracic surgery in a wide range of clinical settings, particularly for anatomical pulmonary resections. Furthermore, this approach may help bridge the gap between conventional multiport RATS and uniportal techniques by combining technical stability with reduced invasiveness.

INTRODUCTION:Chronic expanding hematoma (CEH) is a slowly enlarging hematoma that persists for more than 1 month after the initial hemorrhagic event. Intrathoracic CEH is rare and often requires technically demanding surgery because of dense adhesions and the risk of massive intraoperative bleeding. We report a case of giant intrathoracic CEH managed using a surgical strategy that included preoperative selective transcatheter arterial embolization (TAE). CASE PRESENTATION:A 49-year-old man with a history of tuberculous pleuritis approximately 10 years earlier was referred to our hospital because of a gradually enlarging asymptomatic right intrathoracic mass. Contrast-enhanced CT revealed a 95-mm heterogeneous mass with peripheral enhancement, consistent with CEH. Selective embolization of the right 8th to 11th intercostal arteries was performed on the day before surgery. Through a posterolateral thoracotomy with resection of the 7th and 8th ribs, the hematoma was completely resected with partial resection of the right lower lobe. Additional procedures, including decortication, adhesiolysis, and chest wall plasty, were performed to facilitate lung re-expansion and reduce the residual thoracic cavity. Although prolonged postoperative air leakage required pleurodesis on POD 10, the patient was discharged on POD 12 without major complications. No recurrence has been observed during follow-up. CONCLUSIONS:Preoperative selective TAE, combined with an appropriate surgical strategy, may reduce intraoperative bleeding and enable safe and controlled radical resection of intrathoracic CEH. Careful preoperative planning, including bleeding control and optimization of the surgical approach, is essential for successful treatment.

Background Thoracoscopic lateral intercostal approaches are commonly used for minimally invasive resection of mediastinal tumors in children. In adults, the subxiphoid approach has gained popularity because of reduced intercostal neuralgia and improved cosmetic outcomes; however, its application in pediatric patients remains limited. Case presentation A 7-year-old boy presented with chest pain and was found to have a 32-mm unilocular cystic tumor in the middle mediastinum. Thoracoscopic reduced-port surgery was performed using a subxiphoid uniportal approach with an additional port placed in the left fifth intercostal space. A 25-mm subxiphoid incision was created, and the retrosternal space was developed with sternal elevation using a retractor system. A chest drain was placed through the intercostal port postoperatively. Bidirectional visualization from the subxiphoid and lateral intercostal ports enabled safe dissection and removal of the tumor, which was surrounded by major vascular structures. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Conclusions The combination of a subxiphoid port and a lateral intercostal port seems to be a feasible option for the resection of mediastinal tumors.

INTRODUCTION:Bronchial or tracheobronchial esophageal fistula following pulmonary resection is a rare complication, and involvement of the contralateral main bronchus is extremely uncommon. CASE PRESENTATION:A 78-year-old woman underwent right lower lobectomy with systematic mediastinal lymph node dissection for primary lung cancer. Her initial postoperative course was uneventful, and she was discharged on POD 2. On POD 14, however, she presented with coughing and vomiting during oral intake. Further evaluation revealed a bronchoesophageal fistula (BEF) between the contralateral left main bronchus and the esophagus. Review of the intraoperative video did not demonstrate intentional direct manipulation of the left main bronchus or the esophagus; however, inadvertent contact during hemostasis of subcarinal #7 lymph node (LN #7) tissue cannot be completely excluded. Therefore, delayed thermal injury associated with soft coagulation during LN #7 dissection was considered a possible contributing mechanism in this case. The patient was initially managed conservatively with fasting, total parenteral nutrition, and enteral feeding via a jejunostomy, resulting in gradual reduction of the fistula. After adequate resolution of local inflammation, additional endoscopic clipping from the esophageal side was performed, achieving complete closure. CONCLUSIONS:This case suggests that energy devices, particularly soft coagulation, may be associated with delayed thermal injury even in areas not directly manipulated. Furthermore, a stepwise treatment strategy based on initial conservative management may be effective for small BEFs with localized inflammation in selected cases.

To compare the short-term outcomes and the incidence of post-thoracotomy pain syndrome following dual- versus multi-portal robotic-assisted thoracic surgery. We retrospectively analyzed a database of 287 patients from two institutions in Japan that perform dual- and multi-portal robotic-assisted thoracic surgery between September 2019 and August 2024. Patients underwent surgery for non-small cell lung cancer and were evaluated for short-term outcomes. Propensity score matching was performed to address differences in the patients’ background characteristics between the two surgical groups. Logistic regression analyses were performed to identify the risk factors for post-thoracotomy pain syndrome after robotic-assisted thoracotomy. Before matching and compared with the multi-portal group, the dual-portal group underwent fewer segmentectomies (p = 0.002) and had fewer dissected lymph nodes (p = 0.014). Patient’s characteristics were similar between the groups after matching. There was no significant difference in the short-term perioperative outcomes of both groups. The dual-portal group experienced a significantly lower rate of post-thoracotomy pain syndrome than the multi-portal group (p = 0.038). The predictive factors for post-thoracotomy pain syndrome in the multivariate analysis were multi-portal thoracic surgery and postoperative complications. The short-term outcomes after dual- and multi-portal robotic-assisted thoracic surgery were comparable. However, multi-portal surgery was a predictive factor for post-thoracotomy pain syndrome.

Objective:To introduce and evaluate the non-assistant help operation in dual-portal robotic-assisted thoracic surgery (neoDRATS), a novel technique designed to eliminate the need for skilled assistants by using all 4 robotic arms independently during anatomical lung surgery. Methods:Patients were placed in the lateral decubitus position under general anesthesia with single-lung ventilation. The da Vinci Xi Surgical System was used, with specific configurations for right- and left-side operations. The neoDRATS technique used a 4-cm working port and a 1.8-cm secondary port, with detailed guidelines for optimal setup and robotic arm manipulation. Results:The neoDRATS approach demonstrated successful surgical outcomes without the need for a skilled assistant. The use of a 0° camera and careful placement of instruments minimized interference within the thoracic cavity. The technique provided smooth operability and minimized postoperative discomfort. Video demonstrations of right and left upper lobectomies are provided to illustrate the approach. Conclusions:NeoDRATS offers a practical, safe, and minimally invasive alternative to conventional multiportal and uniportal robotic-assisted thoracic surgeries. This technique simplifies the surgical process, particularly in settings with limited availability of skilled assistants, and represents a significant advancement in robotic thoracic surgery. Further refinement and clinical integration of neoDRATS are anticipated as robotic innovations continue to evolve.

Robotic-assisted thoracic surgery (RATS) has gained increasing interest in recent years and is becoming more widely adopted worldwide. However, because robotic platforms are designed for four robotic arms, four to five incisions have been considered necessary for most thoracic approaches, which is contrary to the concept of minimal invasiveness. Given the evolution of the multiport-to-uniport approach in video-assisted thoracic surgery, it is expected that RATS will also move toward reduced ports. Recently, uniportal RATS (URATS) approaches have been reported in the pursuit of minimally invasive procedures. However, URATS is an approach that requires specialized techniques and knowledge. Furthermore, URATS has disadvantages associated with the limited space available in small patients with small thoracic cavities. In such cases, the assistant substitutes a hybrid technique using a thoracoscopic stapler. In our opinion, it is important that the benefits of robotic surgery, namely surgical maneuverability and staple stability, are maintained in the approach to reduced-port RATS. Herein, we introduce a dual-portal RATS (DRATS) surgical technique performed through two incisions, which adds a stapler port on the caudal side in addition to the main surgical incision. As the da Vinci Xi Surgical System is not a single-port platform, we believe that DRATS is a valid approach in its current state.

Background:Uniportal video-assisted thoracoscopic surgery (U-VATS) offers good cosmetic outcomes with minimal pain for the treatment of primary spontaneous pneumothorax (PSP). Moreover, the early removal of postoperative chest drains reduces postoperative pain and hospitalization duration for patients with PSP. We aimed to investigate the safety and feasibility of drainless U-VATS in patients with PSP and compare postoperative outcomes between specialists and residents. Methods:We retrospectively analyzed data obtained from the medical records of consecutive patients diagnosed with PSP who underwent surgery at Yamagata Prefectural Central Hospital and Tokyo Metropolitan Bokutoh Hospital between April 2023 and March 2024. Yamagata Prefectural Central Hospital and Tokyo Metropolitan Bokutoh Hospital initiated the drainless protocol in April and July 2023, respectively. All surgeries were performed using the U-VATS approach with a 1.8-2.0-cm incision. Results:We retrospectively reviewed the medical records of 54 patients who underwent U-VATS according to the protocol. Postoperative repeated drainage was not required for any patient. The median postoperative length of hospital stay was 1 day. No multiport conversions were required. The specialists performed significantly better than the residents based on operative time; however, the other perioperative outcomes were not significantly different. Conclusions:Protocol-compliant drainless surgery for PSP is safe and feasible. The results from the two institutions suggest that residents can adequately perform U-VATS for spontaneous pneumothorax with perioperative outcomes comparable to those of specialists.

Robotic-assisted thoracic surgery (RATS) has gained increasing interest in the last few years and is becoming more widely adopted worldwide thanks to significant technical advantages such as stereoscopic visualization, accurate and complex movements, camera stability, and a shorter learning curve compared to video-assisted thoracoscopic surgery (VATS). However, because robotic platforms are designed for four robotic arms, four to five incisions have been considered necessary for most thoracic approaches, which contrasts with the concept of minimal invasiveness. The blending of the uniportal approach with robotic technology would bring enormous improvements in safety, effective and postoperative recovery. Recently, uniportal RATS (URATS) approaches have been reported in the pursuit of minimally invasive procedures. However, specific skills are needed to perform URATS. Although there are increasing reports of URATS using the da Vinci single-port (SP) robot system for mediastinal tumor resection, there have been only a few reports detailing the surgical technique of URATS using the da Vinci Xi system. The da Vinci SP platform is too wide to use an approach via the intercostal space because of the 2.5 cm cannula. In the other hand, the da Vinci Xi platform is suitable to use an approach via the intercostal space because of the 8 mm cannula. Herein, we report the surgical technique of URATS using the da Vinci Xi system with innovative port placement. This surgical technique causes less intercostal invasive injury and is suitable for mediastinal tumor resection in hospitals that do not already have a da Vinci SP system. Our experience and literature suggest that URATS for mediastinal tumor procedures is safe and effective and should be considered as a valid additional surgical option.

Uniportal video-assisted thoracoscopic surgery( VATS) is a thoracoscopic surgery in which a camera and multiple forceps are inserted into one wound and the operation is performed under complete monitoring. Since Diego Gonzalez-Rivas reported on lobectomy in 2011, various other procedures such as pneumonectomy, segmentectomy, sleeve, double sleeve, and carina reconstruction have been performed. Now, it is performed not only in Asia and Europe, but also in South America, the Middle East, and other parts of the world. The advantage of uniportal VATS is that the wound is small and only one intercostal space is damaged, which reduces postoperative wound pain and preserves cosmetic appearance. In addition, since the camera and forceps enter through the same wound, the operation can be performed intuitively, and in case of bleeding or other emergencies, a port can be added to switch multi-portal VATS or extend the wound to shift thoracotomy. On the other hand, the disadvantages are the insertion of multiple forceps through one wound, which may limit operability and interference, and tend to be solo surgery, which requires the skill of the surgeon. This time, the video of uniportal VATS for each lung lobe will be presented and the surgical techniques will be explained.